Frequently Used Forms

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Provider Dispute Resolution Request Form 

Prior Authorizations
Behavioral Health Prior Authorization Form
Behavioral Health Therapy Prior Authorization Form (Autism)
Applied Behavior Analysis Referral Form
Community Based Adult Services (CBAS) Request Form

Q4 2023 PA Code Matrix
Q3 2023 PA Code Matrix
Q2 2023 PA Code Matrix
Q1 2023 PA Code Matrix
Q4 2022 PA Code Matrix
Q3 2022 PA Code Matrix
Q2 2022 PA Code Matrix
Q1 2022 PA Code Matrix
Q4 2021 PA Code Matrix
Q3 2021 PA Code Matrix
Q2 2021 PA Code Matrix
Q1 2021 PA Code Matrix
Q4 2020 PA Code Matrix
Q3 2020 PA Code Matrix
Q2 2020 PA Code Matrix
Q1 2020 PA Code Matrix
Q4 2019 PA Code Matrix
Q3 2019 PA Code Matrix
Q2 2019 PA Code Matrix
Q1 2019 PA Code Matrix
Q4 2018 PA Code Matrix
Q3 2018 PA Code Matrix
Q2 2018 PA Code Matrix
Q1 2018 PA Code Matrix

Continuity of Care Form
Prior Authorization 2018 Guide
Prior Authorization 2019 Guide
Prior Authorization 2020 Guide
Prior Authorization 2020 Guide v2
Prior Authorization 2021 Guide
Prior Authorization 2022 Guide
Prior Authorization 2022 Guide v2
Prior Authorization 2023 Guide

Referral Forms
CS Short-Term Post-Hospitalization Housing Referral Form
CS Respite Services – Home Referral Form
CS Day Habilitation Programs Referral Form
CS Recuperative Care Referral Form
CS Personal Care and Homemaker Services Referral Form
CS Medically Tailored Meals Referral Form
CS Housing Transition Navigation Referral Form
CS Housing Tenancy and Sustaining Referral Form
CS Housing Deposits Referral Form
CS Community Transition Services Referral Form
CS Asthma Remediation Referral Form
Pregnancy Referral Form
Care Management Referral form
Behavioral Health Coordination of Care Form
Enhanced Care Management Member Referral Form
CS EAA Home Modifications Referral Form
CS Transition to ALF or RCFE Referral Form
Community Health Worker Referral Form

Physician Certification Statement

Medical Benefit (HCPCS/J-Code) Drug Prior Authorization Form
Prescription Drug Prior Authorization Request Form

Verio Healthcare Provider Request Forms for DME Equipment and Supplies

Other Forms and Resources

Provider Information Data Form
Medi-Cal Non-Covered Services
Member Grievance Form (English)
Member Grievance Form (Spanish)
Member Grievance Form (Arabic)
Member Grievance Form (Chinese)
Member Grievance Form (Hmong)
Member Grievance Form (Russian)
Member Grievance Form (Vietnamese)
Member Grievance Form (Tagalog)
Member Grievance Form (Farsi)
Allowed In-Office Lab Test List, effective 5-15-2018

Contracted Providers Making Changes
Membership Panel Form


Health Education Forms

Health Education Referral Form
Health Management Services Flyer (for Members only) (English | Spanish | Arabic | Vietnamese)
Health Education Services Provider Resources Flyer (for Providers only)

Cultural & Linguistic Services Forms
Member Resources for Cultural and Linguistic Services(English | Spanish | Arabic)
Provider Resources for Cultural and Linguistic Services (English)


Smoking Cessation Resources

CA Quits Toolkit - A Guide to Integrate Tobacco Treatment into Health Systems
Support Groups and Classes
ACOG Guidelines – Smoking Cessation During Pregnancy



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